Advancement in Supraglottic Airways

Speaker- Dr Mohammed zahid yergatti, DA(DNB)

Moderator- Dr Madhavi singh, MD

Definition

• These are airway devices that facilitate oxygenation and ventilation without endotracheal intubation. Some also refer them as extraglottic

Classification Based on sealing mechanism• Perilaryngeal sealers- • All LMAs• I-Gel• Air- Q Intubating laryngeal airway

• Pharyngeal sealers-• Combitube• Streamlined liner of pharynx airway(SLIPA)• Laryngeal tube

• Both• Cobra perilaryngeal airway(cobra PLA)

Based on evolution• First generation devices- simple airway tubes

• Classic LMA• Flexible LMA• CobraPLA

• Second generation- with addition of drainage tubes• Proseal LMA• I-Gel • LMA supreme• SLIPA

• Third generation- cuffless, two drain tubes, small bowl• Baska mask.

Timeline- few out of 17 variants• Classic laryngeal mask airway(cLMA)- 1988• Esophagael tracheal combitube- 1988• LMA fastrach- 1995• LMA Proseal- 2000• Laryngeal tube- 2003• I-Gel-2003• Air-Q- 2004• LMA supreme- 2007• Baska mask ~2012

LMA- laryngeal mask airway

• Dr archie brain is first credited with invention and development of LMA

• He first used a goldmans mask and attached it a obliquely cut endotracheal tube.

• It was introduced in 1988.

Classic LMA

Main shortcomings- • Bending of tip, if we keep pushing during insertion it can push

the epiglottis over larynx and cause obstruction of airway• Rotation and dislodgment of the bowl, • lesser sealing pressure, more risk of aspiration, inaccurate

placement

Esophageal- tracheal combitube

• PVC double lumen with two inflatable cuffs

• Ventilation either through tracheal or oesophageal port

• Distal ballon either seals trachea or oesophageous.

advantages

• Requires minimal training and minimal mouth opening• Useful in non fasted pts during emergency

disadvantages• Only adult and small adult sizes available • Oesophagel trauma• Problems in maintaing seal with movement.

Porseal LMA

Developed basically for more better sealing pressure and acsess to oesophaeous.

Modifications over classic LMA-Larger and deeper bowl with no grilleDarinage tube running parallel to airwayLarger deeper bowl and dorsal exension of cuff

Advantages over classic LMA

• Gastric tube port- for gastric access, checking correct positioning, bougie guided insertion.

• Dorsal cuff- better seal and airway pressure- not present in 2 ½ & below.– with drain tube occluded it prtected airway to

soiling pressures of 68cm of H20*• Bite block• Strap/Hinge for hooking the bougie/introducer.

*Evans NR, Gardner SV, James MF. ProSeal laryngeal mask protects against aspiration of fluid in the pharynx. Br J Anaesth 2002; 88: 584–7

Disadvantages over cLMA

• More incidence of trauma, equivocal incidence of sore throat*

• Slightly longer insertion time compared to cLMA.

• 20% more airway resistance than cllasic airway.

*Brimacombe J, Keller C, Fullekrug B, et al. A multicenter study comparing the ProSeal™ and Classic™laryngeal mask airway in anesthetized, nonparalyzed patients. Anesthesiology 2002; 96: 289–95.

Comparison of PLMA with cLMA

Performance of proseal

Laryngeal tube

• Multi use , single lumen• Two low pressure cuffs- distal and proximal• Two anterior oval ventilating ports between the cuffs.

advantages

Easy insertionMinimal mouth opening required. High ventilation pressure can be usedCan be used to intubate trachea

disadvantagesAirway obstruction- narrowingTrauma to pharynxCuff rupture

I-Geltm

• Single-use non-inflatable mask made of a gel-like thermoplastic elastomer.

• Epiglottic rest to prevent epiglottic downfolding

• Gastric access channel (not present in size 1)• Built-in bite block• Buccal cavity stabiliser

Lisa Sohn • Razan Nour • Narasimhan Jagannathan-Update on Airway DevicesCurr Anesthesiol Rep (2015) 5:147–155 DOI 10.1007/s40140-015-0100-2

• Advantages- – It has better anatomical fit and improves its airway

seal as it approaches body temperature.– Less risk for injuries related to cuff hyperinflation

and decreases the time for successful insertion.– i-gel in meta analysis has been found to be having

greater airway leak pressures and superior fibreoptic views compared to other SGAs.

– Wide lumen allows for airway rescue and assisted intubation.

– Effective in prone position rescue.

video

• Large inflatable plastic cuff no post cuff.• Finns in the mask of bowl to prevent epiglottic

obstruction.• Pharyngeal seal intermediate between cLMA and

Proseal LMA.

LMA supreme

Advantages• Reinforced tip- less chance of folding.• Anatomic curve facilitates insertion• Oval cross section for improved stability.

disadvantages• Drain tube runs through the middle of airway

dividing it into narrow two lumens- limiting its use for intubation, airway inspection.

• PVC is more harder and more traumatic than silicone.

SLIPA-Streamlined Liner of the Pharynx Airway

• Plastic uncuffed disposable• Hollow boot shaped distal part• Anatomically fits pharynx

– Toe rests in oseophageal entrance– Bridge fits in pyriform fossa– Heel – anchors to softpalate– Large size prevents aspiration of regurgitated fluid

advantges

• Greater airway sealing pressue for PPV• cuffless

disadvantages• More trauma• Prone to airway variability as occupies pace

upto softpalate.

Baska mask

• 3rd generation supraglottic irway• Smaller bowel compared to other LMAs- less

risk of including oesophageal opening• Adjustable tab in shaft to increase angulation to

allow easy negotiation of oropharyngeal curve• Double gastric channel- one channel is open to

air so less chance of oesophageal wall impinging the gastric opening during suction

• Bigger distal gastric channel opening so more larger particulate can be sucked out

• During extubation – if pt bites the bowl the gastric channels can be opened for airway.

• Cuffless- membranous bowl which inflates during each positive pressure.

video

• The mean insertion time was lesser than PLMA*

• It had higher sealing pressures than PLMA- 29.98+- 8.51 vs 24.5+-6.19 cm of H2O*

*Sharifa Ali Sabeeh Al-Rawahi et al- ORIGINAL ARTICLE – A comparative analysis of the Baska® Mask vs. Proseal® laryngeal mask for general anesthesia with IPPV- Anaesthesia, Pain & Intensive Care-ISSN 1607-8322, ISSN (Online) 2220-5799

Role in difficult airway algorithm

• Clear recommendation by Difficult airway society 2015 guidelines in both anticipated and unanticipaed difficult airway.

• Specially important in can’t intubate, can’t ventilate situations

• Laryngeal mask exchange recommended in at risk extubations*

*DAS 2015 guidelines

Airway rescue with proseal LMA case reports

Airway rescue with i-gel

• i-gel is established in emergency airway control. Case reports are present where it has been used for airway rescue when cLMA and PLMA have failed*

• I-gel has been used for airway rescue in prone position**

*Anaesthesia, 2008, 63, pages 1010–1026- Use of an i-gelTM for airway rescue**The use of a laryngeal mask airway for emergent airway management in a prone child.Dingeman RS, Goumnerova LC, Goobie SM Anesth Analg. 2005 Mar; 100(3):670-1

Supraglottic airway guided ET intubation and fibre optic laryngoscopy

• LMA fastrach• LMA proseal• LMA supreme• I-gel• Air q• Ambu aura• Slipa

Comparing fibreoptic views through supraglottic airways*

(1) full view of glottis (2) vocal cords, arytenoids, and inferior surface of epiglottis visible (3) only superior surface of epiglottis visible (4) no part of epiglottis or larynx visible

*BioMed Research International Volume 2015 (2015), Article ID 201898, 8 pageshttp://dx.doi.org/10.1155/2015/201898Comparison of Five 2nd-Generation Supraglottic Airway Devices for Airway Management Performed by Novice Military Operators

DAS guidelines for fibreoptic intubation with Supraglottic airway

video

Thank you